Healthcare Provider Details

I. General information

NPI: 1003299173
Provider Name (Legal Business Name): SUNSHINE DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10411 LAGRIMA DE ORO RD NE
ALBUQUERQUE NM
87111-3727
US

IV. Provider business mailing address

10411 LAGRIMA DE ORO RD NE
ALBUQUERQUE NM
87111-3727
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-0456
  • Fax: 505-298-4467
Mailing address:
  • Phone: 505-298-0456
  • Fax: 505-298-4467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number1865
License Number StateNM

VIII. Authorized Official

Name: DR. LILIAN HAYDEE JAIME
Title or Position: PRESIDENT
Credential: DMD
Phone: 505-298-0456